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Feb, 23. 2015 12: 12PM No, 5148 P. 3 <br /> SWRCB,January 2002 Page of <br /> See on ary Containment Testing Report For <br /> This form is lhtetaded for use by contractors performing periodlc testing of UST secondary containment systems. Use the <br /> appropriate pages of thisform to report results for all components tested The completed form, written testprocedures, and <br /> printouts from tests(fapplicable),should be provided to the facility owner/operator for submittal to the"local regulatory agency. <br /> 1. FACILITY WORKATION <br /> Facility Name: �0 ` 1� 1 Date of Testing; 2 <br /> Facility Address: ' , , <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: -r 5 <br /> Name of Local Agency Inspector fafpresent during testing): <br /> 2. TESTING CONTRACTOR WO TION <br /> Company Name: Wayne ferry,Inc <br /> Technician Conducting Test: ow V t"v ICC# 5' 11S_ 7 3 5'- <br /> —a 11 JIMA <br /> Credentials: 0 CSLB Licensed CouLraetor D SWRCB Licensed Tank Tester <br /> License Type: A,B, cl0,C21/D40 Ilaz JLi;eense Number: 300345 <br /> Manufacturer Trafnfnt <br /> Manufacturer Component(s) Date Training Expires <br /> Furnished Upon Request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component ]Pass Fail Not :Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 'c Li.vt?S T7 ❑ 0 ❑ ❑ 0 ❑ ❑ <br /> ❑ n 0 ❑ ❑ ❑ ❑ <br /> r MP q7-1 Pd ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ° <br /> 17- 1 ❑ ❑ ❑ ❑ D D ❑ <br /> 91 g1 ❑ ❑ D ❑ ❑ ❑ 0 <br /> -4 1 4ir7-1 2 D ❑ ❑ D ❑ ❑ 0 <br /> 7-z ® ❑ ❑- ❑ ❑ 0 0 ❑ <br /> 1 ® ❑ D 0 ❑ 0 ❑ ❑ <br /> ❑ ❑ ❑ 0 0 0 ❑ 0 <br /> ❑ ❑ 0 0 0 ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ ❑ ❑ D ❑ <br /> ❑ D I ❑ ❑ a d ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests; <br /> CERTIFICATION OV TECHNICLAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated In this document are accurate and hi full compliance with legal requirements <br /> Technician's Signature: � Date; <br /> Received Time Feb- 23, 2015 12: 21PM No- 8181 <br />